4/16/2015 Short Necks, Juxtarenal and Pararenal Disclosures Aneurysms:Open Repair is the Gold Standard •NONE Michael S. Conte MD Division of Vascular and Endovascular Surgery UCSF Heart and Vascular Center Continued Evolution of EVAR Continued Evolution of EVAR •Suprarenal fixation •Suprarenal fixation •Improved flexibility •Improved flexibility •Larger diameter grafts for larger necks •Larger diameter grafts for larger necks •Smaller caliber delivery systems/PEVAR •Smaller caliber delivery systems/PEVAR •Fenestrations, “snorkels”, “chimneys” •Fenestrations, “snorkels”, “chimneys” •Hybrid procedures- “De-branching” •Hybrid procedures- “De-branching” •Branched grafts •Branched grafts • Technical feasibility may not equal clinical success 1
4/16/2015 Relative Indications for Open Repair Definitions •Juxtarenal or Suprarenal extent •Juxtarenal- extends up to renal arteries and may •Unfavorable Neck include inferior border •Symptomatic Visceral Occlusive Disease •Pararenal- involves the renal arteries; some •Major renal artery arising from AAA authors include JRAA with these •Severe Aortoiliac Occlusive Disease •Suprarenal- aneurysm extends above renals •Known or suspected infection •Connective tissue disease e.g. Marfan •Paravisceral- involves SMA ± celiac •Inadequate caliber access vessels •Type IV TAAA- involvement extends to diaphragm level as high as pulmonary ligament •Bilateral hypogastric exclusion in younger pt •Young, good-risk patient Paravisceral Aneurysm Paravisceral AAA: Treatment Choices •Open repair using bevelled anastomosis, Crawford patch and/or individual branch reconstructions •Branched graft repair •Hybrid approach combining debranching and EVAR 2
4/16/2015 Pararenal AAA Paravisceral/Type IV TAAA: Operative Approach Pararenal AAA Challenging Neck 3
4/16/2015 BAD IDEA Para- and Juxta-renal AAA: Treatment Choices •Open repair using suprarenal or supraceliac clamp •Retroperitoneal or transperitoneal approaches •With or without renal artery reconstruction •Fenestrated EVAR •EVAR with “snorkel” grafts for one or both renals •Branched graft repair •Hybrid approach combining debranching and EVAR Suprarenal Repair: Contemporary Results • Meta analysis of 21 studies, N=1,256 pts, 1986-2008 • Perioperative mortality 2.9% (95% CI 1.8-4.6) •BWH Series N=171 (1990-2006) elective SRAAA • Postoperative renal dysfunction in 0-39% (median •30- day mortality: SR 1.8% IR (N=849) 1.2% 18%) of patients •Postoperative renal impairment • New onset dialysis 3.3% •SR 17% IR 9.5% (p=.003) • Wide range of techniques and definitions precludes •New onset dialysis rare (0.6% SR, 0.8% IR) specific assessment of optimal strategies such as •Postop decline linked to preop RF, renal revasc clamp location, adjuncts •Five year survival: SR 67% IR 69% JVS 2009;49:873-80 J Vasc Surg 2010; 52:760-7 4
4/16/2015 • Single center (MGH) experience 2001-2007, N=199 • NSQIP data 2005-2008; N=3,569 open repairs • Left flank retroperitoneal approach in >90% • Infrarenal AAA N=2820; complex N=592 • Mean f/u 41 ± 28 months • 30 day mortality 5.1% vs 5.7% (NS) • 30-day mortality 2.5% • Mortality higher (8.9%) for group requiring visceral • Perioperative renal insufficiency 8.5%, 2% dialysis • Postop renal artery occlusion 3% of imaged arteries artery bypass • Higher morbidity rates for complex AAA repairs– • Five year survival 74% • Graft-related complications 2% at 40 months cardiac, pulmonary and renal • Increased age, steroid use, preop renal insufficiency negative predictors of long term survival J Vasc Surg 2011; 54:952-9 J Vasc Surg 2012; 56:2-7 Fenestrated EVAR for JRAA •Early studies have shown favorable technical success and 30-day mortality (2-3%) •F/u has been generally limited 1-2 years 2.1% mortality 16%-30% renal impairment •Proximal migration rates as high as 14% at one 13.5%-22.6% reinterventions year have been reported •Branch vessel patency >90%; renal impairment in up to 22% •Approximately 20% reintervention rate within two years •First FDA approved device (Cook) on US Market 5
4/16/2015 “ Chimneys” and “Snorkels” for JRAA 7.1% 30-d mortality •Modest sized single center series with limited 25% early endoleaks follow-up (generally 1 year or less) No postop AAA enlargement •30 day mortality 0-12% •Type I endoleak up to 12% •Long term renal artery patency, sac behavior, endoleak rates unclear •Should likely be reserved for unique anatomic subset of high-risk patients Conclusions •Contemporary results of open repair for juxta- and para- renal AAA from referral centers show mortality is comparable to infrarenal AAA, and durability of repair is excellent. However postoperative morbidity > open infrarenal repair. •Increased age and baseline renal impairment are important risk factors for postoperative mortality •Early results of fenestrated and snorkel EVAR suggest low mortality but substantial rates of endoleak and reintervention; learning curve appears significant and durability is unknown • Younger (<75), average risk patients with PRAA should be offered open repair at experienced aortic centers as the current “gold standard” treatment option 6
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